Re: disc prolapse in pregnancy
From: ainsron@msn.com
Thu Sep 14 10:25:30 2000
But, to play the Devil's advocate, if this patient "sees" a reason to do
a C/S, if she is afraid that labor is going to make her problem worse -
without evidence based medicine to back her up - and you have presented
her with the risks, benefits, etc. of vaginal birth vs. C/S, don't you
feel that she can make that choice? In the case of patient autonomy vs.
paternalism, the patient's choice should always come out on top. If you
disagree, re-read the article in ACOG clinical review, v5, #2, 3-4/2000,
by Benson Harer: "The role of the physician is clearly one of informing
the patient. Ideally, the patient will integrate the information so
that both will be satisfied with the ultimate decision. In real life,
it often does not work that way, in which case the patient's choice
should prevail. If that choice is sufficiently contrary to the
physician's values, the physician should withdraw from the case." ACOG
also says that as physicians, we should refrain from performing
procedures that are not wanted by the pregnant woman. According to my
understanding, that applies not only to "unwanted cesarean sections."
but to "unwanted vaginal births."
>I see no indication for a C/S.
>
>At Wed, 13 Sep 2000, Kirsten Duckett wrote:
>>
>>We have an in-patient who is now 35 weeks in her second pregnancy who was admitted at 28 weeks with sudden onset of back pain after picking up her toddler. The pain was so severe she couldn't move at all and after several days at home with this she then stopped being able to pass urine and was admitted in urinary retention. She had no saddle anaesthesia but did have absent ankle reflexes. An MRI scan showed a significant herniation of L4/L5 disc.
>>
>>Since then she has been managed with analgesia and physiotherapy. Her mobility has improved and her analgesic requirements have dropped. She finds TENS useful. The physio has stipulated that she must remain vertical i.e. either lying or standing , not sitting. Because of this and also the fact that she lives in a second floor flat without a lift and has a 15 month toddler she has remained an inpatient. An elective C/S has been booked for 38 + weeks as there was concern that labour may make the prolapse and pain worse.
>>
>>A medline search found only a few articles and nothing that really says anything about preferred mode of delivery or what to expect post partum. The neurosurgeons have no interest in her while she is pregnant but will see her after delivery.
>>
>>What have other people's experiences been with similar patients particularly with regad to mode of delivery and resolution or otherwise after delivery?
>>
>>Arch Phys Med Rehabil 1995 May;76(5):476-9
>>The lumbar herniated disk of pregnancy: a report of six cases
>>identified by magnetic resonance imaging.
>>
>>LaBan MM, Rapp NS, von Oeyen P, Meerschaert J
>>Department of Physical Medicine and Rehabilitation, William Beaumont Hospital,
>>Royal Oak, MI 48073, USA.
>>
>> Although the mechanical and positional stresses of pregnancy are the primary inciting
>> factors contributing to lumbosacral pain accompanying gestation, in approximately
>> 1:10,000 cases a herniated disk (HNP) can be identified as the proximal cause of
>> pain. Six patients are described, all of whom without antecedent history of pain
>> presented with acute, disabling, gestational lumbosacral, and sciatic radiculopathy.
>> Their ages ranged from 29 to 36, their parity from 0 to 1, and their gestational age at
>> onset of symptoms from 6 weeks to 32 weeks. Each by magnetic resonance imaging
>> (MRI) was identified as having an HNP, 2 at the L4-5 level and 4 at the L5-S1 level.
>> During pregnancy, an MRI evaluation permits a detailed spinal examination without
>> the ionizing effects of x-ray and its acknowledged biological risk to the developing
>> fetus. This potential for an immediate and accurate diagnosis has significant
>> implications for the management and subsequent planning of delivery.
>>
>>Arch Phys Med Rehabil 1983 Jul;64(7):319-21
>>
>> Pregnancy and the herniated lumbar disc.
>>
>> LaBan MM, Perrin JC, Latimer FR
>>
>> During the last decade, five pregnant patients with symptoms and signs of a herniated
>> lumbar disc were identified among a series of 48,760 consecutive deliveries at
>> William Beaumont Hospital, an incidence of 1:10,000. In all cases, clinical
>> evaluation and electromyography complemented conservative treatment during the
>> final stage of pregnancy. Each patient was delivered by cesarean section. Large
>> lumbar disc herniations in each case were subsequently identified by myelography. In
>> all five cases, lumbar laminectomy was successful in facilitating the eventual
>> resolution of the signs and symptoms of the radiculopathy. Although the mechanical
>> and postural stresses of pregnancy have been cited as predisposing causes of a
>> herniated lumbar disc, this study suggests otherwise. Lumbosacral vertebral disc
>> ruptures of pregnancy, while relatively rare, should nevertheless be recognized early,
>> distinguished from other causes of lumbosacral gestational plexopathy, and promptly
>> treated.
>>
>>Radiology 1989 Jan;170(1 Pt 1):125-8
>>
>> Prevalence of lumbosacral intervertebral disk abnormalities on MR
>> images in pregnant and asymptomatic nonpregnant women.
>>
>> Weinreb JC, Wolbarsht LB, Cohen JM, Brown CE, Maravilla KR
>>
>> Department of Radiology, New York University Medical Center, NY 10016.
>>
>> The prevalence of lumbosacral intervertebral disk bulge and herniation on sagittal
>> magnetic resonance (MR) images was determined in 45 pregnant subjects and 41
>> asymptomatic nonpregnant women of childbearing age. MR technique differed for the
>> pregnant and nonpregnant groups. Fifty-three percent of pregnant and 54% of
>> nonpregnant women had an abnormal disk (bulge or herniation) at one or more levels
>> (L3-4, L4-5, or L5-S1). The difference was not statistically significant. There was
>> also no significant difference in the distribution of outcomes among the 45 pregnant
>> subjects, 17 parous nonpregnant women, and 24 nulliparous women. The results
>> suggest that lumbosacral disk bulges or herniations are common in women of
>> childbearing age, whether pregnant or not, and that, contrary to an earlier report,
>> pregnant women do not have an increased prevalence of disk abnormalities.
>>
>>Kirsten Duckitt
>>Clinical Lecturer
>>Nuffield Department of Obstetrics and Gynaecology
>>Level 3, Women's Centre
>>John Radcliffe Hospital
>>Headington
>>Oxford
>>OX3 9DU
>>
>>01865 741166 bleep 1028
>
>--
>"Do not take life too seriously. You will never get out of it alive."
>
>Marianne Williamson
>
--
Ronald E. Ainsworth, MD
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